How Do We Treat Obesity?...Achieve Weight Loss Goals INTENSIFICATION Impart skills and behavior...

How Do We Treat Obesity?

Lifestyle Intervention

2

Why Is Lifestyle Weight Management Important?

Improved metabolic control Lower fasting blood glucose and prevent T2D Lower blood pressure and lipid profile Reduce need for pharmacologic therapy for metabolic

complications associated with obesity

Improved quality of life Less musculoskeletal weight-bearing joint pain Improved GERD, OSA, reactive airway disease

Increased life expectancy Lower incidence of certain cancers

GERD = gastroesophageal reflux disease; OSA = obstructive sleep apnea; T2D = type 2 diabetes.

Lean ME, et al. Diabet Med. 1990;7:228-233. Wing RR, et al. Arch Intern Med 1987;147:1749-1745. Schotte DE, et al. Arch Intern Med. 1990;150:1701-1704.. Dattilo AM, Kris-Etherton PM. Am J Clin Nutr. 1992;56:320-328. Bianchini F, et al. Obesity Rev. 2002;3:5-8. Wadden TA, et al. Obesity (Silver Spring). 2011;19:1987-1998.

4

Components of Therapeutic Lifestyle Change

Nutrition Reduced calorie meal plans Healthy eating patterns

Physical activityHealthy behavior habits Limited alcohol consumption Sufficient sleep Stress reduction (to include behavioral therapy as

necessary)

Handelsman Y, et al. Endocr Pract. 2015;21(suppl 1):1-87.

Intensification of Lifestyle Therapies to Achieve Weight Loss Goals

INTEN

SIFICATIO

N

Impart skills and behavior change to induce and maintain weight loss

Simple advice to lose weight in doctor’s office Internet programs or self-help books Advice from dietitian Structured programs (Weight Watchers, YMCA,

telecommunication)Multidisciplinary structured programs Physician-driven individualized structured

programs

NutritionLifestyle Intervention

6

Reduced Calorie Meal Plans

7Gonzalez-Campoy JM, et al. Endocr Pract. 2013;19(suppl 3):1-82.

A negative energy balance is necessary to achieve weight loss

Recommendation

Generaleatinghabits

Regular meals and snacks; avoid fasting to lose weight Plant-based nutrition (high in fiber, low calories, low glycemic index,

high in phytochemicals/antioxidants) Understand Nutrition Facts Label information Incorporate beliefs and culture into discussions Informal physician-patient discussions Use mild cooking techniques instead of high-heat cooking

Nutritional Components

8Gonzalez-Campoy JM, et al. Endocr Pract. 2013;19(suppl 3):1-82.

Recommendation

Carbohydrates

Understand health effects of the 3 types of carbohydrates: sugars, starch, and fiber

Target 7-10 servings per day of healthful carbohydrates (fresh fruits and vegetables, pulses, whole grains)

Lower-glycemic index foods may facilitate glycemic control:* multigrain bread, pumpernickel bread, whole oats, legumes, apple, lentils, chickpeas, mango, yams, brown rice

Fat

Eat healthful fats: low-mercury/low-contaminant-containing nuts, avocado, certain plant oils, fish

Limit saturated fats (butter, fatty red meats, tropical plant oils, fast foods) and trans fats

Use no- or low-fat dairy products

Protein Consume protein from foods low in saturated fats (fish, egg whites, beans) Avoid or limit processed meats

Micronutrients

Routine supplementation not necessary except for patients at risk of insufficiency or deficiency

Chromium; vanadium; magnesium; vitamins A, C, and E; and CoQ10 not recommended for glycemic control

*Insufficient evidence to support a formal recommendation to educate patients that sugars have both positive and negative health effects.

9

Macronutrient Composition

Meal patterns enriched in the following are associated with a decrease in insulin sensitivity Total fat Saturated fat Trans-fat Refined grains

Meal patterns enriched in the following are associated with an increase in insulin sensitivity Fiber Fruits/vegetables Polyunsaturated fats Monounsaturated fats Whole grain

Gonzalez-Campoy JM, et al. Endocr Pract. 2013;19(suppl 3):1-82.Garvey WY, Lara-Castro C. J Clin Endocrinol Metab. 2004;89:4197-4205.

Features of Different Types of Meal Plans

10Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Shai I, et al. N Engl J Med. 2008;359:229-241.

Meal Plan Calories Composition Recommended food choices

Dietary Approaches to Stop Hypertension (DASH)

1600-3100 kcal/daydepending on individual needs

≤27% fat calories.≤6% saturated fat calories.≤150 mg/day cholesterol.≤3 g/day sodium.

Fruits, vegetables, and low-fat dairy foods.

Low-carbohydrate (Atkins)

No restrictions 20 g/day carbohydrates during 2-month induction phase, with gradual increase to ≤120 g/day carbohydrates.

Vegetarian sources of fat and protein preferred.Avoid trans fat.

Low-fat Women: 1500 kcal/dMen: 1800 kcal/d

30% fat calories.≤10% saturated fat calories.≤300 mg/day cholesterol.

Low-fat grains, vegetables, fruits, and legumes.Limit sweets and high-fat snacks

Mediterranean Women: 1500 kcal/dMen: 1800 kcal/d

≤35% of calories from fat Vegetables , poultry, and fish. Main fat source: 30-45 g/day olive oil and 5-7 nuts (<20 g/ day).Limited red meat.

Adherence Is More Important Than Meal Plan Type for Weight Loss Success

11Dansinger M. JAMA. 2005;293:43-53.

Weight Change by Meal Plan Type

-3.6-3.2

-2.1

-3.8-3.4 -3.2

-3.5 -3.5-3

-3.6 -3.6-3.3

-4-3.5

-3-2.5

-2-1.5

-1-0.5

02 6 12

Atkins (n=40) Zone (n=40) Weight Watchers (n=40) Ornish (n=40)

∆W

eigh

t (kg

)

Months on Diet

P=0.89 P=0.76 P=0.40

Although different diet types did not yield significantly different weight loss, greater diet adherence was significantly associated with weight loss (r=0.60; P<0.001), and

participants in the top tertile of lost an average of ~7% of baseline body weight.

Effect of Low-Fat and Low-Carbohydrate Meal Plans on Weight Over 2 Years

12Foster GD, et al. Ann Intern Med. 2010;153:147-157.

Adults with Obesity(N=307)

0

-8

-12

-14

-10

-6

0 6 12

∆W

eigh

t (kg

)

Months

243

*

*

-4

-2Low-fat meal planLow-carbohydrate meal plan

Lipid Effects of Low-Fat and Low-Carbohydrate Meal Plans

13* P<0.001 between groups. † P<0.01 between groups.

Foster GD, et al. Ann Intern Med. 2010;153:147-157.

Adults with Obesity(N=307)

Low-fat meal planLow-carbohydrate meal plan

0 6 12Months

243

0

-4

-8-10

-6

-2

∆VL

DL

(mg/

dL) 2

-12

**

†

0 6 12Months

243

10

0

-5

5

∆H

DL-

C (m

g/dL

)

** †

*0 6 12

Months243

12

0

-12-18

-6

6

∆LD

L-C

(mg/

dL)

*

0

-20

-40-50

-30

-10

0 6 12

∆Tr

igly

cerid

es (m

g/dL

)

Months243

* *

Healthy Mediterranean Style Eating Pattern

14

Fish, poultry, eggs, yogurt

Fruits, vegetables, whole grains, olive oil, nuts, legumes

*Lean meat preferred.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.

Redmeat,high

fat dairy, processed foods

Food Group Recommended Consumption

Vegetables 2.5 c-eq/day

Fruits 2.5 c-eq/day

Grains 6 oz-eq/day

Whole grains ≥3 oz-eq/day

Dairy 2 c-eq/day

Protein 6.5 oz-eq/day

Seafood 15 oz-eq/week

Meat,* poultry, eggs

25 oz-eq/week

Nuts, seeds, soy 5 oz-eq/week

Oils 27 g/day

Effects of Different Diets on Weight

15

Dietary Intervention Randomized Control Trial (DIRECT)Study Design

322 overweight or obese adults (85% men) 2-year study duration Randomized, controlled design

Diet group Calorie Limit Fat Limit Characteristic nutrition sources

Low fat 1500 for women1800 for men

30% Grains, vegetables, fruits, beans

Mediterranean 1500 for women1800 for men

35% Olive oil, nuts, vegetables, fish

Low carbohydrate

None None 20 g/day of carbohydrate for 2 months, then 120 g/day ofcarbohydratesFat, protein, and vegetables

Shai I, et al. N Engl J Med. 2008;359:229-241.

Effect of Low-Fat, Low-Carbohydrate, and Mediterranean Diets on Weight

16Shai I, et al. N Engl J Med. 2008;359:229-241.

Dietary Intervention Randomized Control Trial (DIRECT)(N=322 Adults with Obesity)

9085

78

0

20

40

60

80

100

Patie

nts

(%)

Weight Change Over 2 Years Adherence Over 2 Years

Low fat Mediterranean Low carbohydrate

Effects of Different Diets on Weight Over Time

17Schwarzfuchs D, et al. N Engl J Med. 2012;367:1373-1374.

Dietary Intervention Randomized Control Trial (DIRECT)

All participants,2 years(n=322)

Completers,2 years(n=272)

Completers,6 years(n=259)

-2.9-3.3

-0.6

-4.4 -4.6

-3.1

-4.7-5.5

-1.7

-6

-5

-4

-3

-2

-1

0

Low fat Mediterranean Low carbohydrate

Mea

n W

eigh

t Lo

ss (k

g)

67

1122

0

20

40

60

80

100

Patie

nts

(%)

6-Year Diet Adherence

Stayedon

original diet

Switched diet

Stopped diet

Effects of Different Diets onGlucose and Lipids Over Time

18

*P<0.001 vs other diets.

FPG = fasting plasma glucose; HDL = high density lipoprotein; LDL = low density lipoprotein; T2D = type 2 diabetes.

Shai I, et al. N Engl J Med. 2008;359:229-241. Schwarzfuchs D, et al. N Engl J Med. 2012;367:1373-1374.

Dietary Intervention Randomized Control Trial (DIRECT)

No diabetes(n=286)

T2D(n=36)

3.1

12.1

3.1

-32.8

1.3 1.2

-40

-30

-20

-10

0

10

20

Low fat

Mediterranean

Lowcarbohydrate

Mea

n FP

G (m

g/dL

)

*

Effect on FPG at 2 Years Effect on Lipids at 2 and 6 Years

Never Smokers Ever Smokers

Effect of Mediterranean Diet Pattern on All-Cause Mortality

19AARP = American Association of Retired Persons; BMI = body mass index; NIH = National Institutes of HealthMitrou PN, et al. Arch Intern Med. 2007;167:2461-2468.

Favors Mediterranean diet

NIH-AARP Diet and Health Study(n=214,284 men; n=166,012 women)

P value

<0.001<0.001<0.001

<0.001<0.0010.002

Favors Mediterranean diet

BMI (kg/m2) P valueMen

18.5 to 25.0 0.0225.0 to <30 <0.001≥30 0.51

Women18.5 to 25.0 0.00125.0 to <30 0.15

≥30 0.12

0.50 1.00 1.50 0.50 0.70 0.90 1.10

Physical ActivityLifestyle Intervention

20

21

AACE Recommendations for Physical Activity Individualize

recommendations according to patient goals and limitations Activities/exercise within

capabilities and preferences Evaluate for

contraindications and/or limitations to increased physical activity before beginning or intensifying an exercise program Set realistic goals and

schedules

Encourage increased nonexercise physical and leisure activity Taking stairs at work,

weekend recreation Consider involvement of

an exercise physiologist or certified fitness professional To individualize physical

activity prescription To improve outcomes

Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

AACE Recommendations forAerobic and Resistance Training

Aerobic Training

Goal ≥150 minutes/week* Greater moderate intensity (ie,

“conversational”) physical activity (eg, brisk walking)

Start slowly and build up gradually Additional 1-3% weight loss seen

when higher intensity aerobic activity is added to a weight loss diet plan

Resistance Training

2-3 sessions weekly* with major muscle groups

Start slowly and build up gradually

Results in improved body composition and metabolic risk factors Greater fat loss and less fat-free

mass loss

22Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

*Higher volume required for weight maintenance

How Much Physical Activity Is Enough?

23

259.9224.5185.7

0

100

200

300

400

Baseline 6 months 12 months 18 months

Lost weight Gained weight Stable weight

*BMI 25.0-29.9 kg/m2. No reduction in energy intake.

BMI = body mass index; DPP = Diabetes Prevention Program; T2D = type 2 diabetes.

Jakicic JM, et al. Obesity (Silver Spring). 2011;19:100-109. DPP Research Group. N Engl J Med. 2002;346:393-403. Look AHEAD Research Group. Arch Intern Med. 2010;170:1566-1575.

Phys

ical

act

ivity

(m

in/w

eek)

Randomized, Controlled, Community Based Study(N=278 Overweight Adults*)

Reduced calorie diet + physical activity required for weight loss in studies with obese patients DPP (prediabetes): >150 min/week Look AHEAD (T2D): >175 min/week

Advice for Physical Activity

24Handelsman Y, et al. Endocr Pract. 2015;21(suppl 1):1-87.

Intensity• At least moderate, physical

activity (conversational—should be able to talk comfortably)

• Heart rate ≥70% of maximum heart rate (max heart rate =220 – age)

Frequency• ≥3-4 times/week• Maintain a regular schedule with

realistic goals)

Motivation• Cross-train (ie, walk, ride, swim)• Use a physical activity partner or

professional trainer or attend organized programs

• Reward self

Support• Health care professional team

must exude positive attitude regarding importance of physical activity

25

Advice for Physical Activity

Hydrate Drink fluids (>18 ounces) 1-2 hours before exercise

Stretch Include warm-up and cool-down periods of 5-10 minutes each

Dress comfortably Wear silica gel or air midsoles and polyester seamless socks

Be safe Check for blisters before and after activity

Patients with T2D, neuropathy, or vascular disease Wear an ID bracelet if needed

Have fun Aerobic and resistance training are both beneficial Be active with a friend

“But Doc, I Can’t Walk Too Far”

26

Any activity is better than no activity!

All patientsLow-impact activity: stationary bicycle, swimming, elliptical machine, stairstepper, treadmill, low-impact aerobics, weight-lifting machine

Foot disease, peripheral vascular disease, arthritis

Swimming, water aerobics, upper body resistance training

Orthostatic conditions

Semi-recumbent chair and weight lifting, semi-recumbent cycling, water exercise

Elderly Stretching while sitting, elastic bands, movement exercise (eg, tai chi, hatha yoga)

Effect of Physical Activity Type and Participation on Weight Loss

27

*≥150 min/week at 6 months but <150 min/week at 12 months. †All groups vs baseline; no group differed significantly from the others at 6 or 12 months.‡Group with ≥200 min exercise vs variable groups and group with <150 min of exercise.

Jakicic JM, et al. JAMA. 2003;290:1323-1330.

Type of Physical Activity Level of Participation

75

80

85

90

Baseline 6 months 12 months

Moderate intensitiy/moderate durationVigorous intensity/moderate durationModerate intensity/long durationVigorous intensity/long duration

P<0.001†

P<0.001‡Wei

ght (

kg)

70

75

80

85

90

95

Baseline 6 months 12 months

<150 min/week at 6 and 12 months (n=31)Variable* (n=81)≥150 min per week at 6 and 12 months (n=33)≥200 min per week at 6 and 12 months (n=51)

Wei

ght (

kg)

*P<0.05 vs control. †P<0.05 vs aerobic exercise. ‡P<0.05 vs resistance training.

SC = subcutaneous.

Davidson LE, et al. Arch Intern Med. 2009;169:122-131.

Effect of Exercise Type on Body Composition

28

MRI Measured Change in Fat and Muscle Mass(N=136 men and women with abdominal obesity)

-0.01-0.52

0.02

-0.04

0.97

-1.56

-0.21 -0.21-0.06

-3.03

-0.43 -0.4

0.62

-3.38

-0.35 -0.4

-4-3.5

-3-2.5

-2-1.5

-1-0.5

00.5

11.5

Skeletal muscle Total fat Visceral fat Abdominal SC fat

Control Resistance Aerobic Combined

Mea

n ch

ange

in ti

ssue

m

ass

(kg)

*†

*‡

*†

*‡

* * * *

Individual Variability in Body and Fat Mass Changes

29

Individual Changes After 12 Weeks of Imposed Exercise(N=30 overweight or obese men and women)

King, NA, et al. Int J Obes (Lond). 2008;32:177-184.

Cha

nge

from

bas

elin

e (k

g)

Patient

-16-14-12-10-8-6-4-2024

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Body weight Body fat

Behavioral InterventionsLifestyle Intervention

30

Lifestyle Intervention Support

Individual Support

Physician consultation and advice Rarely effective alone

Dietitian consultation Must be repeated regularly

Remote structured programs involving Internet and/or phone interactions

Group Support

Clinician-led weight loss support groups

Commercial structured programs (eg, Weight Watchers, Jenny Craig)

Physician-driven multidisciplinary team approaches (eg, DPP, EatRight)

31DPP = Diabetes Prevention Program.

Lifestyle Interventions Are Most Successful When Supported

32

Exercise

Behavioral therapy

Hypocaloric nutrition

Ongoing clinician

follow-up

Physician advice and interestRegular consultation with dietitian

Structured programs(individual or group,

in-person or telephone/Web-based)

Essential for initial weight loss

Essential for maintenance of weight loss

Intensive Lifestyle Interventions for Obesity

33

*P<0.0001 vs DSE.

CV = cardiovascular; DSE = diabetes support and education; ILI = intensive lifestyle intervention; T2D = type 2 diabetes.

Hamman RF, et al. Diabetes Care. 2006;29:2102-2107. Wadden TA, et al. Obesity (Silver Spring). 2011;19(10):1987-1998.

DPP Trial ILI instruction in diet, exercise, and

behavior change in patients with prediabetes First 6 months: ≥16 sessions >6 months: at least every other month

individually or in group Low-fat diet: <25% of caloric intake;

further calorie reduction if no weight loss

Look AHEAD Trial DPP model ILI vs DSE in patients with

T2D and CV risk Factors associated with weight loss

maintenance Weight loss at year 1 Attendance at more treatment sessions Greater adherence to physical activity

and energy intake recommendations

16%

Reduced risk of T2D with each kilogram of weight loss after 3.2 years of follow-up

462325

100

204060

≥5% ≥10%

ILI (mean WL -4.7%) DSE (mean WL -1.1%)

**

Weight loss maintained after 4 years of follow-up

6.011.8

-21.6-13.5

-30-20-10

01020

∆To

tal

Cho

lest

erol

(m

g/dL

)

DEPLOY = Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA; DPP = Diabetes Prevention Program; YMCA = Young Men’s Christian Association.

Ackermann RT, et al. Am J Prev Med. 2008;35:357-363.

DPP Model Community Intervention:Effect on Weight and Total Cholesterol

34

The DEPLOY Pilot Study(N=92)

-2.0 -1.8

-6.0 -6.0-8-6-4-20

∆To

tal W

eigh

t (%

)

Standard DPPP<0.001

4-6 months 12-14 months

P=0.008

P<0.001P=0.002

Montana Diabetes Control Program16-session program based on DPP-style intervention

(N=355)

DPP = Diabetes Prevention Program.

Amundson HA, et al. Diabetes Educ. 2009;35:209-223.

DPP Model Community Interventions Foster Adherence

35

Week

10099989796959493929190

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

350

300

250

200

150

100

50

0

Exercise per week (m

in)M

ean

wei

ght (

kg)

Mean weightPhysical activity7% weight loss goal

Effect of Commercial Portion-Controlled Meal Plan

36DSME = diabetes self-management and education support.

Foster GD, et al. Postgrad Med. 2009;121:113-118.

Nutrisystem Trial in Patients with Type 2 Diabetes(N=69)

DSME (n=34)Portion-controlled meal plan (n=35)

-20

-15

-10

-5

0

5

0 3 6

∆W

eigh

t (%

)

Months

Benefits of Ongoing Behavioral Support

37Appel LJ, et al. N Engl J Med. 2011;365:1959-1968.

Practice Opportunities for Weight Reduction (POWER) Trial(N=415)

No. patients 366 355 392

2

10

-1-2-3-4-5-6

-7-8

0 6 12 24

∆W

eigh

t (kg

)

Months

Self-directed weight lossIn-person supportTelephone/Web-based support

Effects of Commercial Meal Replacement Plan With Ongoing Support

38Rock CL, et al. JAMA. 2010;304:1803-1811.

Jenny Craig Trial(N=442)

∆W

eigh

t (%

)

-10.9

-7.9-9.2

-6.8

-2.6 -2.1

-12

-10

-8

-6

-4

-2

012 months 24 months

Weight loss center–based support (n=167)Telephone-based support (n=164)Usual care (n=111)

P<0.001P<0.001

P<0.001

P<0.001

Effects of Commercial Meal Replacement Plan With Ongoing Support

39Heshka S, et al. JAMA. 2003;289:1792-1798.

Weight Watchers Trial(N=423)

∆W

eigh

t (%

)

-4.3

-2.9

-1.3

-0.2

-5-4.5

-4-3.5

-3-2.5

-2-1.5

-1-0.5

0Year 1 Year 2

Commercial plan (n=211) Self-help (n=212)

P<0.001

P<0.001

Practical Approaches to Lifestyle Interventions for Clinicians

Lifestyle Intervention

40

Physician Discussion of Weight Status and Self-Reported Weight Loss

41NHANES = National Health and Nutrition Examination Survey.

Pool AC, et al. Obes Res Clin Pract. 2014;8:e131-e139.

29

15

23

1314

5

16

5

05

101520253035

Physician discussedweight

Physician did notdiscuss weight

Told of beingoverweight

Not told of beingoverweight

Lost 5% Lost 10%

Respondents Reporting Weight Loss in Past Year

Overweight(n=2405)

Obese(n=2649)

Res

pond

ents

(%)

2005-2008 NHANES

Set Realistic Goals With Your Patient

42

GOAL: decrease risk of complications and improve long-term health

Advise patients to accept steady, incremental progress and emphasize that improved health—not necessarily reduced weight—is the goal• Short-term weight loss goal (for most patients): 7% to 10% loss at 6 months

• Increase in muscle mass may be more important than decrease in fat mass• Interim goal: weight maintenance• Long-term goal (if desired): additional energy deficit recalculated for the next

weight loss goal

Remind patients that reducing caloric intake and increasing physical activity are key to achieving and maintaining weight

Ask patient: What are your goals?

Patients often want to lose ~30% of body weightA weight loss of “only” 7-10% may be deemed as “failure” by patients

43

Lifestyle Therapy for Obesity:Features of Behavior Modification

Office motivational interviewing Goal setting Self-monitoring Mobilization of social support systems

Psychological counseling as needed Problem solving strategies

Stimulus control Stress reduction

Ongoing education and monitoring Face-to-face, group sessions, technologies

Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

Motivational Interviewing

Definition

A guiding style of communication that helps Engage patients in self-care Clarify their strengths and

aspirations Evokes their own motivations for

change Promotes autonomy of decision

making

Technique

Ask Use open-ended questions to

invite the patient to consider how and why they might change

Listen Understand the patient’s

experience Summarize with reflective

listening

Inform Ask permission to provide

information Ask what the implications might

be for the patient

44Rollnick S, et al. BMJ. 2010; 340:c1900. doi: 10.1136/bmj.c1900.

45

Early Weight Loss Supports Long-Term Success

Weight loss of >2.5% in the first month of the DPP predicted long-term weight loss success Stepped care approach involves education on

problem solving skills and evaluation of outcomes Intensify behavioral lifestyle intervention if patients do

not achieve a 2.5% weight loss in the first month Intervention and support should be tailored to each

patient’s ethnic, cultural, and educational background

DPP = Diabetes Prevention Program.

Wing RR, et al. Obes Res. 2004;12:1426-1434.

Importance of Behavior Modification Support for Weight Loss Maintenance

46

Control = always at normal weight; maintainers = formerly >20% overweight but now normal weight; relapsers = currently >20% overweight and had previously lost and regained ≥20% of body weight.

Kayman S, et al. Am J Clin Nutr. 1990;52:800-807.

Interview/Survey Study(N=108 women)

35

60

80

42

82

33

95

70

17

90

70

10

38

2

34

0

20

40

60

80

100Control (n=34) Maintainers (n=30) Relapsers (n=44)

Escapes/avoids

problems(food/alcohol/drug use, excess sleep, wishful thinking)

Confronts problems

Seekssocial

support

Actively reduces tension

(extra work, recreation, relaxation

techniques)

Exercises regularly

Res

pond

ents

(%)

47

Monitor Weight and Reinforce Weight Loss Goals During Follow-up Visits

Monitor and discuss weight status at each visit—open communication is vital Encourage self-monitoring of healthy eating and

regular physical activity Remind patient of health benefits of maintaining a

healthy weight Reinforce realistic short and long-term expectations Encourage continued adherence to healthy lifestyle

and behavioral changes

Lifestyle Therapy in a Real World Setting: Number of Sessions and Weight Loss

48

*Spearman Rank Correlation Test result. Blue line = best fit through the plot.

DPP = Diabetes Prevention Program.

Ali MK, et al. Health Aff (Millwood). 2012;31:67-75.

Systematic Review and Meta-analysis*(N=28 studies of DPP translational model)

Additional 0.26% weight loss with each

additional lifestyle session attended

r2 = 0.902; P<0.001

0 5 10 15 20 25

5

10

15

20

Num

ber o

f ses

sion

s at

tend

ed

Number of sessions offered

Effectiveness of Professional, Lay, and Online Counseling for Weight Loss

49

*Pooled estimates of percentage weight change for each category of delivery personnel (95% confidence interval).

DPP = Diabetes Prevention Program.

Ali MK, et al. Health Aff (Millwood). 2012;31:67-75.

Systematic Review and Meta-analysis(N=28 studies of DPP translational model)

-4.27

-3.15

-4.2 -3.99-5

-4

-3

-2

-1

0

Average Weight Loss by Program Leader/Type*

Wei

ght c

hang

e (%

)

Clinician(n=19 studies)

Lay community member

(n=5 studies)Electronic media

(n=4 studies)Overall

(N=28 studies)

(-5.85, -2.70)

(-5.46, -0.83)

(-7.62, -0.77) (-5.16, -2.83)

50

Recommended Components of Success

A healthy, reduced calorie meal plan Dietitian visits Structured diets Commercial programs amd replacement meals

Aerobic and resistance exercise Trainer, health coach, sports medicine

Behavior change interventions Face-to-face office meetings Group sessions Remote technologies (telephone, internet, text

messaging)

Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

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Lifestyle Therapy Summary

Lifestyle interventions effectively prevent physical and metabolic complications of obesity Lifestyle alone is less effective in populations with higher

stages of obesityWeight loss with lifestyle change is difficult to maintain Behavioral support may need to be intensified to assist with

weight loss and maintenance Initial weight loss benefits are sustained even with weight

regain Support groups Health care professional teams and community groups should

help patients set realistic goals and encourage adherence to healthy weight loss/maintenance behaviors